Provider Demographics
NPI:1386176808
Name:ILIESCU, MICKEY
Entity type:Individual
Prefix:MR
First Name:MICKEY
Middle Name:
Last Name:ILIESCU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7111 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGEVALE
Mailing Address - State:CA
Mailing Address - Zip Code:95662-2813
Mailing Address - Country:US
Mailing Address - Phone:916-821-3091
Mailing Address - Fax:916-987-7165
Practice Address - Street 1:7125 MAIN AVE
Practice Address - Street 2:
Practice Address - City:ORANGEVALE
Practice Address - State:CA
Practice Address - Zip Code:95662-2813
Practice Address - Country:US
Practice Address - Phone:916-987-7285
Practice Address - Fax:916-987-7165
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA347003704311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility